Analysis of the key themes in the healthcare of older people with multimorbidity in Germany: a framework analysis as part of the LoChro trial

Abstract

Objectives: Multimorbidity challenges healthcare systems. In Germany, coordination of healthcare for older multimorbid patients remains unstructured.This study aims to identify key themes in the healthcare of these patients and the inter-relationships between them.

Design: Framework analysis of six cases based on 1-year data of primary and secondary care, patient-answered questionnaires and video material.

Setting: Southern Germany.

Participants: Six multimorbid older patients participating in a randomised controlled trial that compared usual care with a local, collaborative, stepped and personalised care management approach for older people with chronic diseases (LoChro-trial). The LoChro care intervention involved a care manager who assisted participants in self-management. The primary outcome was a composite of functional health and depressive symptoms at 12 and 18 months. The LoChro-intervention had no effect on the primary outcome.

Primary outcome measure: Key themes in the healthcare of older patients with multimorbidity and the inter-relationships between them.

Methods: One-year data included diagnoses, treatment plans, examinations, assessments and discharge reports. Patient perspectives were assessed using the Patient Assessment of Chronic Illness Care. In three cases, videos of the LoChro intervention showed patients describing their health needs. These data were evaluated by three doctors and public health researchers. Using framework analysis, recurring themes influencing the healthcare situation of multimorbid older patients and their inter-relationships were identified.

Results: Participants had an average age of 77, with 13 diagnoses, taking eight medications regularly. The five key themes describing the healthcare situation of these multimorbid patients were as follows: insufficient coordination, overuse and underuse of medical care, doctor and patient roles. Each theme covered three to four subcategories. The most significant inter-relationships between these themes were a lack of coordination leading to overuse and underuse of medical care. These were characterised by redundant inpatient stays, potential prescribing omissions and missed examinations. Deficiencies in vaccinations and secondary prevention were also demonstrated.

Conclusion: Coordination of care for multimorbid older patients in Germany is still deficient. Future healthcare arrangements should be explored with the participation of physicians and patients.

Trial registration number: LoChro trial: DRKS00013904.

Keywords: GENERAL MEDICINE (see Internal Medicine); GERIATRIC MEDICINE; Organisation of health services; PUBLIC HEALTH.

Figure 1

Inter-relationships between key themes and subcategories of the healthcare situation of multimorbid older patients, seen in six underlying cases in Germany. Black arrows: repeatedly observed inter-relationships; coloured arrows: each colour stands for observations corresponding to one patient; crossed arrows: inhibiting relationship.